Classification of fundus autofluorescence abnormal patterns in diabetic macular edema

Introduction: Patients with diabetic macular edema can develop fundus autofluorescence alterations; thus far, these alterations have been more widely studied with scanning or confocal laser systems. Objective: To describe and classify fundus autofluorescence abnormal patterns in patients with diabetic macular edema using the fundus autofluorescence system with a flash camera. Method: Observational, retrospective, cross-sectional, descriptive study. Fundus autofluorescence digital images of non-comparative cases with untreated diabetic macular edema, obtained and stored with a flash camera system, were assessed. Inter-observer variability was evaluated. Results: 37 eyes of 20 patients were included. Lens opacity was the most common cause of inadequate image quality. Five different fundus autofluorescence patterns were observed: decreased (13%), normal (40%), single-spot hyper-autofluorescent (17 %), multiple-spot hyper-autofluorescent (22 %) and plaque-like hyper-autofluorescent (8 %). The kappa coefficient was 0.906 (p = 0.000). Conclusions: Different fundus autofluorescence phenotypic patterns are observed with flash camera systems in patients with diabetic macular edema. A more accurate phenotypic classification could help establish prognostic factors for visual loss or for the design of clinical trials for diabetic macular edema.

Classification of fundus autofluorescence abnormal patterns in diabetic macular edema.

INTRODUCTION: Patients with diabetic macular edema can develop fundus autofluorescence alterations; thus far, these alterations have been more widely studied with scanning or confocal laser systems. OBJECTIVE: To describe and classify fundus autofluorescence abnormal patterns in patients with diabetic macular edema using the fundus autofluorescence system with a flash camera. METHOD: Observational, retrospective, cross-sectional, descriptive study. Fundus autofluorescence digital images of non-comparative cases with untreated diabetic macular edema, obtained and stored with a flash camera system, were assessed. Inter-observer variability was evaluated. RESULTS: 37 eyes of 20 patients were included. Lens opacity was the most common cause of inadequate image quality. Five different fundus autofluorescence patterns were observed: decreased (13%), normal (40%), single-spot hyper-autofluorescent (17 %), multiple-spot hyper-autofluorescent (22 %) and plaque-like hyper-autofluorescent (8 %). The kappa coefficient was 0.906 (p = 0.000). CONCLUSIONS: Different fundus autofluorescence phenotypic patterns are observed with flash camera systems in patients with diabetic macular edema. A more accurate phenotypic classification could help establish prognostic factors for visual loss or for the design of clinical trials for diabetic macular edema.

A Diabetic Retinopathy Screening Tool for Low-Income Adults in Mexico.

INTRODUCTION: A national diabetic retinopathy screening program does not exist in Mexico as of 2017. Our objective was to develop a screening tool based on a predictive model for early detection of diabetic retinopathy in a low-income population. METHODS: We analyzed biochemical, clinical, anthropometric, and sociodemographic information from 1,000 adults with diabetes in low-income communities in Mexico (from 11,468 adults recruited in 2014-2016). A comprehensive ophthalmologic evaluation was performed. We developed the screening tool through the following stages: 1) development of a theoretical predictive model, 2) performance assessment and validation of the model using cross-validation and the area under the receiver operating characteristic curve (AUC ROC), and 3) optimization of cut points for the classification of diabetic retinopathy. We identified points along the AUC ROC that minimized the misclassification cost function and considered various scenarios of misclassification costs and diabetic retinopathy prevalence. RESULTS: Time since diabetes diagnosis, high blood glucose levels, systolic hypertension, and physical inactivity were considered risk factors in our screening tool. The mean AUC ROC of our model was 0.780 (validation data set). The optimized cut point that best represented our study population (z = -0.640) had a sensitivity of 82.9% and a specificity of 61.9%. CONCLUSION: We developed a low-cost and easy-to-apply screening tool to detect people at high risk of diabetic retinopathy in Mexico. Although classification performance of our tool was acceptable (AUC ROC > 0.75), error rates (precision) depend on false-negative and false-positive rates. Therefore, confirmatory assessment of all cases is mandatory.

[Literature review: Diabetic macular edema. Repercussions and treatment]. / Revisión bibliográfica: edema macular diabético, repercusiones y tratamiento.

In our country there is a report of prevalence of Diabetes Mellitus in the adult population of a 10%, occupying one of the first causes of morbidity-mortality, also visual and labor incapacity. Macular edema is the first cause of lost vision in the diabetic patient. There are classic methods to detect it, as the examination with biomicroscope, indirect ophthalmoscopy, fluorangiography (FAR), and the new and gold standard method for diagnostic and sequence examination, Ocular Coherence Tomography (OCT). With OCT had been possible the study of distinct types of macular edema, that could represent distinct clinical states, with specific treatments. The protocol of treatment of macular edema, continues changing. The traditional methods as metabolic control and fotocoagulation with Laser now have more options as intravitreal injection of triamcinolone, or antiangiogenic substances, even surgical treatment with vitrectomy. There are many prospective and randomized studies evaluating this methods, so until now is difficult to determine which treatment is the best.

En nuestro país se reporta que un 10 % de la población adulta vive con diabetes mellitus, siendo esta enfermedad una de las principales causas de morbimortalidad, así como de discapacidad visual y laboral. El edema macular es la principal causa de pérdida visual en el paciente diabético. Existen métodos clásicos para su detección, como el uso de biomicroscópico, la oftalmoscopia indirecta o la angiografía con fluoresceína (AGF), que se han visto superados por nuevos métodos como la tomografía de coherencia óptica (OCT), estándar de oro en la actualidad para su diagnóstico y seguimiento; mediante este, se han estudiado distintos tipos de edema macular, que podrían representar entidades clínicas diferentes que requerirían tratamientos específicos. El enfoque terapéutico del edema macular diabético continúa evolucionando. A los métodos tradicionales de control metabólico y fotocoagulación con láser se han unido, en años recientes, nuevas alternativas como la inyección intravítrea de triamcinolona y sustancias antiangiogénicas, incluso el tratamiento quirúrgico mediante vitrectomía. Continúan realizándose diversos estudios prospectivos aleatorizados para evaluar la mayor parte de estas terapias, lo que hace aún más difícil determinar cuál es el tratamiento más adecuado en cada circunstancia.

Diabetes mellitus: una epidemia mundial / Diabetes mellitus: a global epidemic

La diabetes es una epidemia en desarrollo que aumentará los próximos años. Se muestran una revisión a evidencia clínicos del aumento de la prevalencia de diabetes que asociado al aumento de expectativa a vida, aumentará el riesgo de pérdida visual y ceguera en la población. Otros estudios clínicos, demuestra lo beneficioso del tratamiento adecuado de una diabetes así como el tratamiento precoz de una retinopatía disminuye el riesgo de una pérdida visual. Por toda esta evidencia es necesario organizar un sistema a cuidado ocular que desarrolle estrategias para detectar y tratar una retinopatía diabética evitando una perdida visual, dentro de un programa nacional de manejo de la diabetes. Se resumen algunas recomendaciones entregadas en reporte de Diabetes mellitus de la OMS.

Diabetes is an evolving epidemic disease that will increase in the upcoming years. A clinic evidence review about the increase in diabetes prevalence is showed This fact, besides the increased span of life will increase the risk of visual loss and blindness in the population. Other clinical studies show the benefits of an adequate treatment of diabetes, as well as the early treatment of diabetic retinopathy diminishes the risk of visual loss. Because of this amount of evidence, it is necessary to organize a visual care system and to develop strategies to detect and treat diabetic retinopathy, avoiding visual loss, included in a national program of diabetes. management. Some recommendations of a recent report of OMS about diabetes are summarized.

A genome-wide linkage scan for diabetic retinopathy susceptibility genes in Mexican Americans with type 2 diabetes from Starr County, Texas.

We conducted a genome-wide linkage scan for genes contributing to retinopathy risk using 794 diabetes case subjects from 393 Mexican-American families from Starr County, Texas, having at least two diabetic siblings. The sample included 567 retinopathy case subjects comprising 282 affected sibling pairs. Retinopathy was classified as none, early nonproliferative, moderate-to-severe nonproliferative, or proliferative. Using 360 polymorphic markers (average spacing 9.4 cM), we conducted nonparametric linkage analysis followed by ordered-subset analysis (OSA) ranking families by average age of diabetes diagnosis. For any retinopathy, the highest LOD scores including all families were on chromosomes 3 (2.41 at 117 cM) and 12 (2.47 at 15.5). OSA logarithm of odds (LOD) scores >2 for any retinopathy occurred on chromosomes 12 (4.47 at 13.2 cM), 15 (3.65 at 100.6), and 20 (2.67 at 54.1). Scores >2 for either moderate-to-severe nonproliferative or proliferative retinopathy occurred on chromosomes 5 (2.53 at 11.2 cM), 6 (2.28 at 30.6), and 19 (2.21 at 100.6). Thus, unconditional linkage analysis revealed suggestive evidence of linkage with retinopathy on two chromosomes, whereas OSA revealed strong evidence of linkage on two chromosomes, and suggestive evidence on four. Candidate genes were identified in most implicated regions.

Retinopatia diabética / Diabetic retinopathy

Os autores fazem uma revisão bibliográfica sobre a complicação microvascular mais freqüente e específica do Diabetes Mellitus (DM): a Retinopatia Diabética (RD). É considerada uma grande ameaça à visão em países ocidentais, e é a principal causa de cegueira em pessoas em idade produtiva(9,10)

[Diabetic retinopathy in Martinique: results of a cross-sectional survey based on 771 patients]. / La rétinopathie diabétique en Martinique: résultats d'une enquête transversale sur 771 patients.

INTRODUCTION: Because of the gravity of diabetic retinopathy in Martinique, a cross-sectional survey was conducted between March and September 1996 to estimate the prevalence of this complication on this island. PATIENTS AND METHODS: Clinical data, obtained by examining and questioning 771 diabetic patients (recruited among the usual practice of the ophthalmologists), were analyzed using Epi-Info. RESULTS: Some form of diabetic retinopathy was present in 42%. of the patients and 8.3% presented proliferative retinopathy. A total of 78% of the patients presented a non-insulin-dependent diabetes mellitus, essentially women. Medical supervision of the diabetes and its ophthalmologic complications proved to be insufficient. Principal risk factors found for the prevalence and severity of diabetic retinopathy were a long duration of diabetes, insulin-dependent type diabetes among women and the whole population, age among men, mode of treatment (insulin), and hypertension. DISCUSSION: These results are higher than those usually reported in France. This can be explained by diet and racial factors: the population is mainly of African and Indian descent. Risk factors are the same as those already described in earlier studies. To improve these prevalences, strategies should include classic methods risk factors correction, patients education, increasing coordination between the different medical specialists), but should also take into account the particularities of this Caribbean population such as racial, economic, historical, and sociocultural factors.

Retinopatía en pacientes diabéticos tratados por diferentes especialistas. Reporte preliminar / Retinopathy in diabetics seen by different specialists

Se realizó un estudio retrospectivo para determinar si existen diferentes proporciones de pacientes con retinopatía en grupos manejados por diferentes especialistas médicos.Material y método: Las valoraciones oftalmológicas iniciales de pacientes diabéticos se dividieron de acuerdo al médico que los refirió: grupo 1: endocrinólogos; grupo 2: médicos internistas; y grupo 3: médicos generales. Se comparó la proporción de ojos con: a) retinopatía diabética, b) retinopatía proliferativa y c) pérdida visual severa. Se valoró también la oportunidad de la detección de acuerdo con las recomendaciones internacionales. Las diferencias entre cada grupo se analizaron mediante x2.Resultados: Se valoraron 756 ojos de 387 pacientes. Se asignaron 264 ojos al grupo 1, 152 al grupo 2 y 340 al grupo 3. La proporción general de ojos con retinopatía, con retinopatía proliferativa y con pérdida visual severa fue de 48 por ciento, 16 por ciento y 14 por ciento respectivamente. La presencia de retinopatía diabética, retinopatía proliferativa y pérdida visual severa fue significativamente menor para el grupo 1 al compararlo con los grupos 2 y 3 (p < 0.05), pero las diferencias entre los grupos 2 y 3 no fueron significativas (p > 0.05). La detección no fue oportuna para ninguno de los grupos.Discusión: Debe reforzarse la práctica de la detección de retinopatía por el médico que maneja al paciente diabético y la referencia oportuna para calificación, especialmente durante la formación de pregrado.

Angiofluoresceinografia em serviço de referência: freqüência diagnóstica / Angiofluoresceinography study in a reference service: Diagnostic frequency

Foram analisados 1.0006 angiofluoresceinografias realizadas entre 1996 e 1999, na fundação Altino Ventura e Hospital de Olhos de Pernambuco. Os achados mais frequentes foram: retinopatia hipertensiva em 397 casos (39,5 por cento); retinopatia diabética em 262 (26,0 por cento); e drusas de pólo posterior em 148 (14,7 por cento). Os achados normais estiveram presentes em 114 casos (11,3 por cento). Com exceção de retinopatia hipertensiva e oclusões venosas da retina, não houve diferenças estatisticamente significativas quanto à distribuição do sexo por afecção. Com exceção de atrofia do epitélio pigmentar, houve diferenças estatisticamente significativas (p< ou = 0,002) das prevalências das frequências dos achados nos grupos etários. Conclui-se que os achados angiofluoresceinográficos decorrentes de doenças crônicas são de maior frequência em um serviço de angiofluoresceinografia. Tal fato pode ser explicado pelo motivo de que mais da metade dos pacientes (62,4 por cento) encaminhados para a realização dos exames pertencem ao grupo etário mais idoso

Presentación de la retinopatía diabética en un hospital de población abierta / Diabetic retinophaty presentation in an open population hospital

Objetivo. Identificar la distribución de la retinopatía diabética en un hospital de población abierta. Material y métodos. Se evaluó el fondo de ojo de pacientes diabéticos valorados por primera vez en el servicio oftalmológico de un hospital de población abierta, y se registró el tiempo de evolución de la diabetes. La distribución de la retinopatía se comparó con las de una encuesta de población, un centro de concentración oftalmológico, y un hospital urbano estadounidense. Resultados. se valoraron 471 ojos de 271 pacientes. Doscientos cincuenta y cinco (54.1 por ciento) no presentaban retinopatía y 216 ojos (45.9 por ciento) tenían retinopatía: en 142 (65.7 por ciento) existió retinopatía no proliferativa y en 74 proliferativa (34.3 por ciento). Hubo edema macular en 19 ojos (4 por ciento) y hemorragia vítrea en 28 (5.9). La retinopatía no proliferativa fue más frecuente en ojos con 10 a 14 años de evolución, y la proliferativa, en ojos con 15 a 19 años. La presentación de la retinopatía proliferativa fue más frecuente que en el estudio de población, y en el hospital urbano, (p<0.05), y semejante a la reportada encontrada en el centro de referencia (p > 0.05). Se concluye que la retinopatía se presentó en una proporción similar a la del estudio de población y del hospital urbano, con menor frecuencia de edema macular, y con una proporción de retinopatía proliferativa y hemorragia vítrea similar a la del centro de concentración oftalmológica. Es necesario determinar la causa de la frecuencia elevada de retinopatía proliferativa en población abierta

Incidencia y progresión de la retinopatía diabética en población de nivel socioeconómico bajo de la Ciudad de México / Incidence and progression of diabetic retinopathy in low income population of Mexico city

La retinopatía diabética es de las principales causas de ceguera prevenible en población económicamente activa. La diabetes mellitus afecta frecuentemente a la población mexicana, la retinopatía diabética como complicación microvascular también es frecuente y adquiere formas clínicas más severas cuando se ha comparado con otras poblaciones. No existe ningún estudio de incidencia de esta complicación diabética en nuestro país. En esta investigación, se informa la incidencia y progresión a cuatro años de la retinopatía diabética en una cohorte de pacientes diabéticos tipo 2 habitantes de seis colonias de bajos recursos de la ciudad de México. En la fase de seguimiento, a cuatro años se logró examinar a 164 (76.6 por ciento) del total de la población estudiada en fase inicial, 63 hombres y 101 mujeres. A todos se les realizó un examen oftalmológico completo con esterofotografías de fondo de ojo de siete campos. Estas fotografías fueron graduadas con los criterios internacionalmente aceptados en el Centro de Lectura Fotográfica de nuestra institución. Se concluyó que la incidencia a cuatro años de retinopatía diabética, de cualquier grado es de 22.5 por ciento. Se presentó progresión en 20.6 por ciento y 4.5 por ciento alcanzó la etapa de retinopatía diabética proliferativa. La incidencia se asoció a edad menor de 45 años en el momento del diagnóstico de diabetes mellitus y la progresión, a más de 10 años de tiempo de evolución del padecimiento. La incidencia de edema macular a cuatro es de 8.8 por ciento. Es muy importante difundir estos datos para incrementar el nivel de conciencia y desarrollar estrategias de prevención y atención al paciente diabético en nuestro país

Is the risk of diabetic retinopathy greater in non-Hispanic blacks and Mexican Americans than in non-Hispanic whites with type 2 diabetes? A U.S. population study.

OBJECTIVE: To compare the risk for diabetic retinopathy in non-Hispanic white, non-Hispanic black, and Mexican-American adults with type 2 diabetes in the U.S. population. RESEARCH DESIGN AND METHODS: Representative population-based samples of people aged > or = 40 years in each of the three racial/ethnic groups were studied in the 1988-1994. Third National Health and Nutrition Examination Survey (NHANES III). Diagnosed diabetes was ascertained by medical history interview, and undiagnosed diabetes by measurement of fasting plasma glucose. A fundus photograph of a single eye was taken with a nonmydriatic camera, and a standardized protocol was used to grade diabetic retinopathy. Information on risk factors for retinopathy was obtained by interview and standard laboratory procedures. RESULTS: Prevalence of any lesions of diabetic retinopathy in people with diagnosed diabetes was 46% higher in non-Hispanic blacks and 84% higher in Mexican Americans, compared with non-Hispanic whites. Blacks and Mexican Americans also had higher rates of moderate and severe retinopathy and higher levels of many putative risk factors for retinopathy. Blacks had lower retinopathy prevalence among those with undiagnosed diabetes. In logistic regression, retinopathy in people with diagnosed diabetes was associated only with measures of diabetes severity (duration of diabetes, HbA1c, level, treatment with insulin and oral agents) and systolic blood pressure. After adjustment for these factors, the risk of retinopathy in Mexican Americans was twice that of non-Hispanic whites, but non-Hispanic blacks were not at higher risk for retinopathy. These risks were similar when people with undiagnosed diabetes were included in the logistic regression models. CONCLUSIONS: The prevalence and severity of diabetic retinopathy is greater in non-Hispanic blacks and Mexican Americans with type 2 diabetes in the U.S. population than in non-Hispanic whites. For blacks, this can be attributed to their higher levels of risk factors for retinopathy, but the excess risk in Mexican Americans is unexplained.

Retinopatía diabética en niños y adolescentes diabéticos insulino-dependientes / Diabetic retinopathy in insulin dependent children and adolescents

Objetivo. Conocer el grado de retinopatía diabética en un grupo de diabéticos insulino-dependientes. Material y método. Se realizó estudio oftalmológico a 121 pacientes y a 66 de ellos se les realizó fluoroangiografía de retina. En base a los datos anteriores se clasificó el grado de retinopatía diabética que presentaban y se dio el tratamiento médico-quirúrgico necesario. Resultados. Once ojos (4.5 por ciento) presentaron retinopatía diabética no proliferativa leve; 6 ojos (2.4 por ciento) retinopatía no proliferativa muy severa y 2 ojos (0.8 por ciento) retinopatía proliferativa complicada. Conclusiones. El 7.7 por ciento de los pacientes con diagnóstico de diabetes insulino-dependiente presentaron diversos grados de retinopatía por lo que recomendamos valoraciones oftalmológicas periódicas para su detección y tratamiento

[The incidence and opportunity for the diagnosis of diabetic retinopathy]. / Frecuencia y oportunidad del diagnóstico de retinopatía diabética.

This study aims to establish the frequency of diabetic retinopathy (DR) in patients with diabetes mellitus (DM) type II in Leon, Guanajuato, Mexico, as well as the opportunity for their diagnosis. A prospective study was carried out in a sample of 100 patients. DR was stratified using the classification of the Early Treatment Diabetic Retinopathy Study Research Group and diagnosed in 42 per cent of the sample. The evolution time of diabetes in this group was different from that of the group without RD (p < 0.0001). A direct proportional and significant relationship between the duration of DM and an increasing severity of DR was found. Opportune diagnosis was made in 70 per cent of the cases with DR. In 81 per cent of the 42 patients with DR, no previous diagnosis was made. This study shows a high proportion of RD without diagnosis. The intensification of educational strategies for the opportune detection and early treatment of DR is recommended.